Surgeons' Role in Local Palliation of Esophageal Cancer.

Esophageal cancer commonly presents in advanced stage, and many patients will require palliative intervention. Endoscopic stenting remains an excellent first-line therapy; however, this should be discussed in a multidisciplinary setting, considering expectations for long-term survival.

The Impact of Minimally Invasive Esophageal Surgery.

Many esophageal patients with cancer were undertreated for their malignancy, which played a role in the poor long-term survival rate. Surgeons have been eager to see real change in short-term and long-term outcomes. Dramatic and profound advances continue toward improving surgical outcomes, techniques, and expanding the reach of esophagectomy, especially the use of minimally invasive techniques. This article discusses the surgical innovations that have occurred in the last decade and their impact on patients with esophageal cancer.

Survival after resection of synchronous non-small cell lung cancer.

OBJECTIVES: Our objective was to determine the long-term survival of patients with resected synchronous multiple pulmonary malignant tumors. METHODS: This is a multi-institutional retrospective study of patients who underwent surgical resection of synchronous (nonbronchioloalveolar) non-small cell lung cancer. RESULTS: Between March 1996 and December 2009, 67 patients (30 men) underwent 121 operations. Forty-four patients had bilateral tumors. Positron emission tomographic scans were performed in 58 (87%) patients, computed tomographic scans and magnetic resonance imaging of the brain in 53 (79%), and mediastinoscopy in 56 (84%). N2 lymph nodes were benign in all patients before undergoing resection of bilateral tumors of the same histologic type. Types of resection were lobectomy in 62, sublobar in 73, and pneumonectomy in 1. Eleven patients (16%) had postoperative morbidities. Cancer-specific 3- and 5-year survivals were 73% and 69%, respectively, and overall 3- and 5-year survivals were 64% and 53%, respectively. Subgroup analysis demonstrated no difference in overall survival at 5 years between bilateral tumors of the same histologic type (M1a) (49%) versus different histologic types 42% (P = .88), or between bilateral tumors (50%) and ipsilateral tumors (54%) (P = .83). CONCLUSIONS: The 5-year survival of surgically resected, synchronous, N2-negative, nonbronchioloalveolar, non-small cell lung cancer is excellent, even in patients who have bilateral lung lesions that harbor the same histologic features. Although the new TNM classification system labels this disease as clinical stage IV M1a, survival acts more like a separate T1 lesion after surgical resection. Thus, surgical resection should be considered in appropriately selected patients who have multiple pulmonary malignant tumors that are N2 negative.

Prevention of delayed gastric emptying after esophagectomy: a single center's experience with botulinum toxin.

BACKGROUND: Impaired gastric emptying after esophagectomy contributes to significant morbidity and delayed recovery. Traditional measures to prevent this include pyloromyotomy and pyloroplasty. These procedures are associated with known complications and do not always prevent delayed gastric emptying. Intrapyloric botulinum toxin injection may be an alternative approach to avoiding pyloric obstruction after esophagectomy. METHODS: Patient data were collected in a prospective fashion at a single institution. Forty-eight patients underwent intrapyloric botulinum toxin injection during esophagectomy during a 26-month period (October 2005 to January 2008). Three patients were excluded from analysis because of complications, which interfered with postoperative evaluation of emptying. Forty-five patients were evaluated clinically for signs of delayed gastric emptying. Objective assessment included a dysphagia score in 15, barium swallow in 43, and nuclear gastric emptying scans in 15 patients. The data were also reviewed for evidence of aspiration events leading to pulmonary complications. RESULTS: Forty-three of 45 patients (96%) had no clinical evidence of delayed gastric emptying in the immediate postoperative period. Four barium studies were interpreted as delayed gastric emptying; however, only 2 patients were symptomatic. These 2 patients underwent balloon pyloric dilation, which resulted in resolution of symptoms in 1. Three additional patients exhibited "late" delayed gastric emptying after initially doing well (mean of 3 months postoperatively) and required endoscopic intervention. No complications were identified in the study related to botulinum toxin injection. CONCLUSIONS: Intrapyloric injection with botulinum toxin is a simple, safe, and effective means of avoiding delayed gastric emptying after esophagectomy. When necessary, reintervention may be performed endoscopically.

Thoracoscopic esophageal mobilization during minimally invasive esophagectomy: a head-to-head comparison of prone versus decubitus positions.

BACKGROUND: Minimally invasive esophagectomy (MIE) is being performed at an increasing number of institutions. The thoracoscopic portion is generally performed in the left lateral decubitus position. Recently there has been increasing interest in esophageal mobilization in the prone position and the potential benefits of this technique with regard to operative time, surgeon ergonomics, and operative exposure. We sought to objectively compare thoracoscopic mobilization of the esophagus in the left lateral decubitus position versus the prone position and identify potential differences between the two techniques. METHODS: A retrospective review of a prospectively maintained esophagectomy database identified 44 patients undergoing MIE during a 20-month period (June 2005-February 2007). Of these, 32 patients underwent thoracoscopic esophageal mobilization with cervical esophagogastric anastomosis. Eleven cases were performed in the left lateral decubitus position and 21 performed in the prone position. RESULTS: The patients were comparable in age, tumor stage, and fraction undergoing neoadjuvant therapy. There was no statistically significant difference between decubitus position and prone position with regard to number of lymph nodes procured (14.6 versus 15.5, p = 0.69), complications (6/11 versus 10/21, p = 1.0), length of stay (9 versus 10 days, p = 1.0), or intraoperative blood loss (85 versus 65 cc, p = 0.14). Thoracoscopic operative times were significantly shorter in the prone group than the decubitus group (86 versus 123 min, p = 0.0001). CONCLUSIONS: Prone thoracoscopic esophageal mobilization appears to be equivalent to decubitus thoracoscopic esophageal mobilization with respect to blood loss, number of lymph nodes dissected, and complications, but with a significant reduction in thoracoscopic surgical time.

Fibrin glue in pulmonary resection: a prospective, randomized, blinded study.

BACKGROUND: In contrast to the rare large-airway bronchopleural fistulas after lung resection, peripheral or alveolar air leaks (AAL) are very common, often prolong hospital stay, increase utilization of resources, and on occasion result in significant morbidity. Various adjuncts have been used in attempts to reduce AAL. One of these, the topical application of fibrin glue, has to date failed to demonstrate efficacy in small clinical trials. This study reexamines the role of fibrin glue in routine lobar and wedge pulmonary resections. METHODS: Of 113 patients enrolled, 13 became ineligible because of intraoperative findings. The remaining 100 patients were randomly assigned to one of two groups at the conclusion of lung resection, regardless of the presence or absence of identifiable air leak. The control group received no additional intervention. The experimental group underwent application of 5 mL of fibrin glue delivered by a pressurized, aerosolized spraying mechanism. Postoperatively a blinded clinical observer recorded outcomes including the incidence and duration of AAL, prolonged AAL (PAAL), the volume of pleural drainage, the time to tube removal, and the postoperative length of stay (LOS), as well as any complications related to treatment. RESULTS: Both groups were comparable with regard to demographics, diagnoses, and procedures. Statistically significant reductions were found in the experimental group in the overall incidence of AAL (34% versus 68%, p = 0.001), mean duration of AAL (1.1 versus 3.1 days, p = 0.005), mean time to chest tube removal (3.5 versus 5.0 days, p = 0.02), and the incidence of PAAL (2% versus 16%, p = 0.015). There was no significant difference in the volume of chest tube drainage or LOS (4.6 days glue and 4.9 days control, p = 0.318). There were no complications related to the use of fibrin glue. CONCLUSIONS: Aerosolized fibrin glue appears to be safe and effective in reducing AAL. The overall incidence of AAL was reduced by 50% and PAAL occurred in only 1 treated patient (2% versus the usually reported 15%). Further studies with this and other methods are required to delineate routine versus selective use, to compare methods, and clarify cost benefit.